of the *
hereby constitute and appoint
agent for the said company, in my name, place and stead to vote as proxy at the meeting of the Wisconsin Compensation Rating Bureau to be held on the 9th of May, 2024, and/or such other date or dates to which such meeting may be adjourned, hereby giving to agent power and authority to act conclusively for such company on all questions which may duly come before such meeting as fully as I could act if I were personally present.
IN WITNESS WHEREOF, I have hereunto subscribed my name and title and the name of
said company, this 22 day of April 2024.


(Email Address)
(Phone Number ###-###-####)
* Voting by Group
This ballot is being executed on behalf of the following listed subscriber companies which are affiliates of the above company
(Please list one company per line):
By selecting the SUBMIT PROXY FORM button below, I declare all the information above to be true and accurate to the best of my knowledge. I give Wisconsin Compensation Rating Bureau the right to investigate the information given for verification purposes for this WISCONSIN COMPENSATION RATING BUREAU PROXY FORM only.